For the past year, I have served on the board of a clinic in a neighborhood in Philadelphia that serves the working poor. The people in Germantown have seen improvements in infrastructure, crime control and commerce to come to other areas of the city, but not to their neighborhood. Public education has been underfunded and in crisis for decades, limiting the opportunities of the young to go on to college, to obtain a well-paying job and to be provided health insurance as part of an employment package. The dismal state of public education, however, continues to limit prospects for housing, food, and healthcare.
The patients served by the clinic almost universally have the triad of hypertension, hyperlipidemia and diabetes. They tend to be overweight or obese as a consequence of having little access to supermarkets offering fresh fruits and vegetables rather than the fare sold at corner bodegas.
Most of the patient present to the clinic for the first time after having symptomatic, untreated diseases for years. The lack of health insurance coupled with their inability to access Medicaid due to excessive income, even though these wages are low. Even when care is provided and medications are accessed through pharmaceutical access programs, there are significant limitations to services for after-hours care, radiological studies, and surgery. A patient with diabetes had increasing difficulty with his glucose levels because cataracts decreased his ability to draw up the correct dose of insulin or to see well enough to cook his food. What he needed was a cataract extraction but without insurance, access to ophthalmological surgery was impossible.
Why should geriatric providers care about patients who lack access to healthcare? Without access to healthcare in young and middle adulthood, these patients age poorly if at all and develop the consequences of diseases in older adulthood that make treatment more difficult and costly. What will geriatric medicine look like in the decades after the Affordable Care Act becomes implemented? Will we see an improvement in chronic disease management, an increase in life expectancy for the poor and a healthier geriatric population in the decades to come?
